What's the point of ST elevation?

OBJECTIVE: The magnitude of ST elevation is a key piece of information in the decision to thrombolyse in acute myocardial infarction. The ability of clinicians to reliably identify ST elevation has not been previously assessed. This study sought to determine the variability in assessment of ST elevation in a group of doctors who commonly prescribe thrombolysis. METHODS: The study was conducted in three large teaching hospitals in Manchester, England. A convenience sample of 63 SHOs and SpRs from emergency and general medicine were recruited. Each was shown three sample ECG complexes. They were asked to identify and quantify the degree of ST elevation. They then indicated the points on the ECG from which they measured ST elevation. RESULTS: ST elevation was not identified in 12% of cases. Doctors used a wide variety of points on the ST segment to assess elevation, this resulted in a wide variation in the observed magnitude of ST elevation. CONCLUSION: No guidance exists on where exactly ST elevation should be measured. This study shows a wide variation in practice. Protocol led thrombolysis decision pathways may be compromised by these findings.

Trauma systems--state of the art.

Trauma is an inevitable consequence of the lives we lead. There are many approaches to dealing with it but an ideal system, universally applicable, probably does not exist because of the national variations in social, economic, cultural and geographical characteristics. Many countries are beginning to recognise that the 'systems' they have in place for dealing with the burden of trauma are seriously deficient and that this situation cannot be allowed to continue into the new millennium. However, it is highly unlikely that in the near future. governments will suddenly find substantial extra finance for trauma care or the implementation of new systems. Throughout many countries, the individual components of trauma care systems are in place but, for whatever reasons, there is a lack of integration, which results in suboptimal care. The system we all should be aiming for is one of closer communication and greater cooperation. By taking into account community and national needs, available resources, and adapting what is currently in place it should then be possible to create 'a set of things working together as parts of a trauma mechanism'.

Accident and emergency medicine in the United Kingdom.

This article describes the history and current status of the practice of hospital-based accident and emergency (A&E) medicine in the United Kingdom of Great Britain and Northern Ireland. Included are comments on training and certification, the operations of the typical A&E department, and developments in research and academics. Also included are the authors' thoughts on issues of future importance to A&E medicine. As transatlantic links at all levels become increasingly common in this dynamic specialty, we clarify unfamiliar terminology and practices for international readers.

Management of eye emergencies in the accident and emergency department by senior house officers: a national survey.

OBJECTIVE: To assess the training that accident and emergency (A&E) senior house officers (SHOs) receive in dealing with eye emergencies, their own perceived level of confidence and competence in managing such cases, and the availability of appropriate equipment in their departments. METHODS: Prospective telephone survey using a standardised structured questionnaire. One SHO from each United Kingdom A&E department listed in the BAEM directory of 1993 was chosen at random and interviewed. RESULTS: 226 A&E departments were contacted and 192 SHOs were successfully interviewed (response rate 84.9%); 26.0% received no training in the management of eye emergencies, 68.8% had only a little or no confidence in dealing with these cases, and 42.2% worked in A&E departments which had no slit lamp. CONCLUSIONS: There is a lack of adequate basic ophthalmic training for A&E SHOs, leading to a lack of confidence on their part in the management of eye emergencies. In just over 40% of A&E departments in the United Kingdom, the management of these cases may be less than optimal because of the absence of a slit lamp.

The ability of A&E personnel to demonstrate inhaler technique.

OBJECTIVE: To determine the ability of accident and emergency (A&E) personnel to demonstrate metered dose inhaler technique. METHODS: 25 senior house officers and 25 nurses working in A&E were individually interviewed and assessed on their knowledge of inhaler technique and competence in demonstrating the correct use of a metered dose inhaler. RESULTS: Demonstration of inhaler technique was generally poor by the staff assessed. Although 22 (88%) of the senior house officers were aware of the British Thoracic Society guidelines, only 10 (40%) routinely checked inhaler technique when discharging asthmatic patients. CONCLUSIONS: The A&E department offers an important opportunity for patient assessment and reinforcement of metered dose inhaler technique. Staff should be made aware of the British Thoracic Society guidelines and be competent at assessing and teaching inhaler technique.

Traumatic disruption of the thoracic aorta: a rational approach to imaging.

An imaging strategy is crucial in patients who have sustained a traumatic disruption of the thoracic aorta. Of those who reach hospital alive, 70-90 per cent will survive if diagnosed early and treated appropriately. The clinician has many imaging techniques to choose from, but they vary considerably in their degree of accuracy and performance time. Consequently their appropriateness is dependent on the type of injury suspected, the haemodynamic stability of the patient and the availability and experience of the radiologists. This article describes the types and presentation of traumatic thoracic aortic disruption so that the advantages and disadvantages of the various imaging modalities can be explained. It concludes by presenting an imaging strategy for use when this condition is suspected.

The trauma team--a system of initial trauma care.

Trauma remains the leading cause of death under the age of 35 years. England and Wales lost 252,000 working years from accidental deaths, including poison, in 1992. In this country, preventable deaths from trauma are inappropriately high. In many hospitals there are not enough personnel; in the majority, there are no recognisable trauma care systems, which can reduce preventable deaths to a minimum. The appropriateness of trauma centres for this country is being assessed in Stoke-on-Trent, and a report is due out later this year. Even if the recommendation is made to establish such centres, it is unlikely that many will be set up. Consequently most hospitals will have to rely on their own resources to set up and run a trauma team. This type of trauma care system is the subject of this article.

Advanced trauma life support.

From a family tragedy 20 years ago, ATLS has truly become an international trauma care program. Its success is demonstrated not only in the large number of physicians that have been trained, but also in the appearance of a number of affiliated courses with a similar structure, aimed at training medical, nursing, civilian and military personnel in how to deal with trauma in a variety of settings. A great deal of time and money has been spent on reaching this point and ATLS has undoubtedly had a profound effect on members of the medical profession worldwide. Few would doubt that ATLS has contributed to the overall improvement in the care of the victims of trauma and saved lives; yet we still lack the evidence to support what many of us feel so strongly about. We are now faced with the next major stage in the development of ATLS, namely to provide the evidence for the efficacy of this in an acceptable scientific manner. It is a challenge we should accept with the same enthusiasm that originally embraced ATLS, and where better to meet this challenge than within the countries of Europe?

Trauma audit--closing the loop.

The philosophy of medical audit and methods of data collection and statistical analysis have been extensively reviewed but less has been written about the effect of audit on medical practice. The measurement of performance is only valuable if it identifies areas of concern and stimulates appropriate change. This paper describes the work of the Salford Trauma Audit Group which has been developed at Hope Hospital, the problems that have been recognized, the strategies that have been introduced to effect change and their influence on management and outcome. Analysis of performance reveals an initial fall in adjusted mortality rate from severe injury after the introduction of resuscitation teams, the adherence to Advanced Trauma Life Support protocols and an integrated multidisciplinary approach to trauma care. Problems remain and there is continuing concern about trauma management in the hospital. This has been reinforced by performance feedback through the Trauma Audit Group which has attracted the interest of senior clinicians in several specialties.

ABC of emergency radiology. The wrist.

History including detailed mechanism of injury. Meticulous clinical examination. Appropriate radiograph and systematic assessment.

ABC of emergency radiology. The ankle.

The os trigonum is a common normal variant of the talus and is due to a separate ossification centre arising from the posterior tubercle. The appearance may resemble an old ununited fracture fragment. However, it is triangular, well corticated, in a classic location, and usually bilateral, which enables it to be distinguished from a fracture. Transverse, sclerotic, linear lines located at the metaphysis of growing long bones are due to short periods of growth arrest and have no clinical importance (fig 5). They may be confused with compression fractures, but again these lines are usually bilateral. Fibrous cortical defects are the most commonly seen benign lesions of long bones and are usually identified incidentally in radiographs taken for another reason. The defect is limited to the cortex, commonly found at the metaphysis, but may be located in the diaphysis as the bone grows. The lesion is well corticated (sclerotic margins) and usually does not produce signs or symptoms.